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Case Management and Diabetes Mellitus

Case Management and Diabetes Mellitus. Shirley Descheenie-Effland, RN Suzanne Lipke, APRN, BC-ADM, CDE Charlton Wilson, MD. Diabetes Case Management.

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Case Management and Diabetes Mellitus

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  1. Case Management and Diabetes Mellitus Shirley Descheenie-Effland, RN Suzanne Lipke, APRN, BC-ADM, CDE Charlton Wilson, MD

  2. Diabetes Case Management Case management is part of the clinical component in which efforts are made to assist the client in achieving their highest level of diabetes self management.

  3. Steps For Diabetes Case Management • Assessment • Analysis of assessment findings • Outcome identification • Planning • Diabetes Self Management Education • Evaluation • Follow up • Program effectiveness

  4. Assessment • Determine the priority of information obtained by the client’s immediate condition or need • Include the client’s family • Collect the information in a systematic manner • Document findings in a retrievable format

  5. Assessment • Integrate the assessment process with data from other members of the health care team to ensure continuity and collaboration • Include information related to client’s knowledge of diabetes and current diabetes self-management behaviors.

  6. Analysis of Assessment • Identify actual or potential problems and/or challenges and barriers • Identify interpersonal, cultural , psychosocial and environmental conditions that affect the client • Validate findings with the client, family and health care team • Document findings in a manner that identifies outcomes • Incorporate findings into an individualized care plan

  7. Outcome Identification • Formulate outcomes from assessment findings • Determine that outcomes are realistic, attainable and measurable • Ensure that outcomes reflect scientific knowledge of diabetes care • Use outcomes to evaluate goal attainment

  8. Planning • Assist client with developing goals • Patient selected plan - Individualize the plan to meet the client’s needs • Identify priorities in relation to expected outcomes • Document the plan • Collaborate with other team members about the plan

  9. Diabetes Self-Management Training • Provide diabetes education that is pertinent to the client’s assessed needs and health values • Use appropriate teaching methods • Allow opportunities for the client to demonstrate skills • Incorporate empowerment strategies • Document understanding of education

  10. Evaluation • Evaluate outcomes on a systematic and on-going basis • Document client’s response to implementing the care plan • Evaluate the effectiveness of interventions in relation to outcomes • Revises plan as needed • Documents revisions • Collaborates with team on evaluation

  11. Follow - Up • Determine frequency of follow-up • Use a systematic approach for each follow up visit • Provide client with feed back • Incorporate a tracking system to avoid “lost to follow-up” status

  12. Case Management Interventions • Supportive Counseling • Readiness for Change • Motivational Interviewing • Problem Solving • Skills building • Monitoring • Individualized Care Plans • Coordination of Resources

  13. Things to Consider • Age-appropriate, culturally, ethically and spiritually sensitive care and support • Educate patients, families and support systems • Continuity of care • Coordination of care for various settings • Managing information • Effective communication with diabetes team • Non-judgmental approach

  14. Diabetes Case Managers Qualitative Experiences • Developing inter-personal relationships helps to build trust • Persistence is required and rewarded • Individual assessment facilitates the development of a care and education plan

  15. Care Plan Using the PCC+ Form

  16. Standing Orders • Staged Diabetes Management

  17. -Glucosidase Inhibitor Dose Adjustments (in mg) Start Next Next Up to Max Acarbose 25 mg/day 25 mg bid 25 mg tid 100 mg tid Miglitol 25 mg/day 25 mg bid 25 mg tid 100 mg tid May be increased by 25 mg/day/week if tolerating dose; maximum dose of Acarbose is 50 mg tid for people who weigh <60 kg (132 lbs); clinically effective dose 50-100 mg tid before meals. (From SDM Detection and Treatment Quick Guide) -Glucosidase Inhibitors

  18. Metformin Dose Adjustments (in mg) Start PM Next AM/PM Next AM/PM Next AM/PM Max AM/Mid/PM Metformin 500 mg 500 500/500 500/1000 1000/1000 1000/500/1000 Metformin 850 mg 850 850/850 850/850/850 May be increased weekly when using 500 mg tablets or every other weekly when using 850 mg tablets. (From SDM Detection and Treatment Quick Guide) Metformin

  19. Sulfonylurea Dose Adjustments (in mg) Start AM Next AM Next AM/PM Next AM/PM Max AM/PM Glyburide 2.5 5 5/5 10/5 10/10 Micro.Glyburide 1.5 3 6/- 9/- 12/- Glipizide 5 10 15/- 10/10 20/20 Glipizide XL 5 10 15/- 20/- Glimepiride 1 2 3/- 4/- 8/- May be increased every 1-2 weeks. (From SDM Detection and Treatment Quick Guide) Sulfonylureas

  20. Thiazolidinedione Dose Adjustments (in mg) Start Next Max Pioglitazone 15 30 45 Rosiglitazone 4 8 8 Thiazolidinedione dose may be adjusted every 8-12 weeks. (From SDM Detection and Treatment Quick Guide) Thiazolidinediones

  21. Glyburide/Metformin (Glucovance) Dose Adjustments (in mg glyburide / mg metformin) Start AM Or Start AM and PM Or Start AM and PM Next AM/PM Max AM and PM Glucovance 1.25/250 mg 1.25/250 1.25/250 and 1.25/250 Glucovance 2.5/500 mg 2.5/500 and 2.5/500 5/1000 and 2.5/500 Glucovance 5/500 mg 5/500 and 5/500 10/1000 and 10/1000 May be increased weekly when using 250 or 500 mg metformin tablets or every other weekly when using 1000 mg metformin tablets. (From SDM Detection and Treatment Quick Guide) Combinations

  22. Bedtime NPH Insulin Adjustments <80 mg/dl 140-250 mg/dl >250 mg/dl AM or 3:00 AM  PM N 1-2 units  PM N 1-2 units  PM N 2-4 units Insulin

  23. Insulin Stage 2 Pattern Adjustments RA/N – 0 – RA/N – 0 or R/N – 0 – R/N – 0 <80 mg/dl 140-250 mg/dl >250 mg/dl AM or 3:00 AM  PM N 1-2 units  PM N 1-2 units  PM N 2-4 units Midday  AM RA or R 1-2 units AM RA or R 1-2 units AM RA or R 2-4 units PM  AM N 1-2 units  AM N 1-2 units  AM N 2-4 units <100 mg/dl 160-250 mg/dl >250 mg/dl Bedtime  PM RA or R 1-2 units  PM RA or R 1-2 units  PM RA or R 2-4 units Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide). Insulin

  24. Insulin Stage 3 Pattern Adjustments RA/N – 0 – RA – N or R/N – 0 – R – N <80 mg/dl 140-250 mg/dl >250 mg/dl AM or 3:00 AM  PM N 1-2 units  PM N 1-2 units  PM N 2-4 units Midday  AM RA or R 1-2 units  AM RA or R 1-2 units  AM RA or R 2-4 units PM  AM N 1-2 units  AM N 1-2 units  AM N 2-4 units <100 mg/dl 160-250 mg/dl >250 mg/dl Bedtime  PM RA or R 1-2 units  PM RA or R 1-2 units  PM RA or R 2-4 units Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide). Insulin

  25. Insulin Stage 4 Pattern Adjustments RA – RA – RA – N or G or R – R – R – N or G <80 mg/dl 140-250 mg/dl >250 mg/dl AM or 3:00 AM  BT N or G 1-2 units  BT N or G 1-2 units  BT N or G 2-4 units Midday  AM RA or R 1-2 units  AM RA or R 1-2 units  AM RA or R 2-4 units PM  Mid RA or R 1-2 units  Mid RA or R 1-2 units  Mid RA or R 2-4 units <100 mg/dl 160-250 mg/dl >250 mg/dl Bedtime  PM RA or R 1-2 units  PM RA or R 1-2 units  PM RA or R 2-4 units Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide). Insulin

  26. Insulin 70/30 Pattern Adjustments <80 mg/dl 140-250 mg/dl >250 mg/dl AM  PM 70/30 1-2 units  PM 70/30 1-2 units  PM 70/30 2-4 units Midday  AM 70/30 1-2 units AM 70/30 1-2 units AM 70/30 2-4 units PM  AM 70/30 1-2 units  AM 70/30 1-2 units  AM 70/30 2-4 units <100 mg/dl 160-250 mg/dl >250 mg/dl Bedtime  PM 70/30 1-2 units  PM 70/30 1-2 units  PM 70/30 2-4 units Insulin

  27. RPMS/DMS/EHR • Examples

  28. DEPTH Registry Individualized to PIMC

  29. AIc • Clinical Benefits • Educational Benefits

  30. 2005 DEPTH OutcomesAll People with DM vs DEPTH Completers

  31. 2005 DEPTH OutcomesAll People with DM vs DEPTH Completers

  32. 2005 DEPTH OutcomesAll People with DM vs DEPTH Completers

  33. Resources • Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002; 22:15-38. • Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Implications for Workforce Development, Diabetic Medicine 2005; 22:1116-1120.

  34. Resources • American Association of Diabetes Educators. The Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. The Diabetes Educator 2005; 31(4): 487-512.

  35. Resources Coming Soon • Best Practices in Diabetes Case Management

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